My McKnight’s Article: RCS1 v. RUG4

The Centers for Medicare & Medicaid Services is proposing to radically change how they pay skilled nursing facilities to care for Medicare patients after hospital stays. Today, under the RUG IV rule and formula, the economic engine of the facility is the rehab department and the fuel for that engine is the volume of minutes of therapy provided by physical, occupational, and speech therapists.

The more minutes of therapy, the higher the payment. Are there unintended consequences from the current model? Of course. I think we’ve all sadly seen examples of cringeworthy decisions and care plans made to capitalize on the current model. With the possible replacement of RUG IV with RCS-1, CMS is not looking to fix the engine. They’re removing it.

As I’ve talked with administrators, nurses, and therapists about RCS 1 over the past couple weeks, the reaction has been consistent:

  1. Blank Stares followed by
  2. Disbelief followed by
  3. Minds Racing to predict the consequences.

Why?

1. BLANK STARES – Because it’s a paradigm shift

Most of us have a general idea how the RUG4 formula works for rehab patients: take the minutes and adjust based on some of the ADL (activities of daily living) scores found in the MDS.

The RCS1 formula to determine a daily PPS rate is, at a high level, this is to determine why the patient is admitted to the SNF.

  1. Why is the patient here?
    10 categories: Major Joint or Spinal, Non-Orthopedic, Acute Neurologic, Non-surgical orthopedic/Musculoskeletal, Orthopedic Surgery (Except Major Joint), Cancer, Acute Infections, Pulmonary, Cardiovascular & Coagulation, Medical Management
  2. What is the functional status of the patient?
    Higher functioning, less dependent = higher score/payment
  3. What is the cognitive function of the patient?
    Higher cognition = higher score/payment
  4. Is the patient depressed?
    Depressed patients = higher score/payment
  5. What non-therapy ancillary things are going on with the patient?
    IV med, Feeding tubes, Dialysis, etc. = higher score/payment
Why pay less for patients that are more dependent? That runs counter to what we’re used to. I speculate the rationale is that the more independent and cognitively sound a patient is, the more therapy they are able to receive.

2. DISBELIEF – What about therapy minutes?

Notice there is zero input for therapy minutes. As RCS-1 is drafted today, the daily rate for that patient is the same whether s/he received 10 minutes or 1,000 minutes of PT/OT/ST.  Re-read that sentence as many times as you need to until your mind starts racing. Then read on …

3. MINDS RACING – How will we adapt?

Could RCS-1 mean an unintended windfall for operators?  Maybe.

Let’s compare the RUGIV and RCS1 payment for a couple common Medicare SNF patient types. Let’s choose Kansas City as our market.

Slide1

The source for the RCS-1 rate is from the Zimmet Healthcare Services Group online calculator. I highly recommend Zimmet to anyone in the industry who wants to learn in depth about this and wants to stay on top of the latest changes to reimbursement/regulations. (I have no financial interest in Zimmet.).

CMS is notorious for underestimating operators’ ability to pivot to the changing goal posts. Can you imagine a replay of 2011/2012 when the change to RUG4 resulted in a windfall for savvy operators followed by an immediate cut by CMS to fix it (see Medicare rate chart)?  I can.

Slide2

Keeping the minutes static, the daily profit increases by $177 and $342 for the stroke and joint replacement patients respectively. But the RCS-1 formula begs the question: why would you keep the minutes static? The minutes/RUG thresholds are artificial constructs by CMS. When those thresholds disappear, what does care planning by the PT/OT/ST look like? Will they give more or less? What will the directives be from management?

Can you see the pendulum swinging too far for some organizations that try to cut therapy to the bone since it will become a cost center (financially speaking)? I can.

Plus: How will rehab companies and/or rehab departments change how they care plan? More group/concurrent therapy? More use of aides in the states that allow it? More use of RNAs? More intense rehab during the first half of the stay?

Here’s the thing, love them or hate them, the minutes thresholds provides everyone (management and clinicians) with a framework that encourages therapy to be given but also provides a “governor” on how much therapy is given. What’s the governor or regulator under RCS-1? Patient outcomes. Is that it?  Looks that way to me.  

Any operator who wants to maintain or grow their Medicare market share must earn it today. Bagels are being replaced by data — length of stay, readmission rates by diagnosis, episodic cost of care, star ratings — to determine short-term patient market share.

RCS-1 doesn’t change that reality. How can you possibly attract short-term patients and deliver optimal outcomes on those data points without exceptional (sufficient & effective) PT/OT/ST?  I don’t see it. Nevertheless, I would anticipate rehab companies and rehab departments to drive more efficiency — cutting out the gray-area treatments that milk the minutes but are not the most effective/efficient methods. How are outsourced rehab companies preparing for this?  Are they going to continue to charge the same way or will they develop new metrics?

I think we’ll develop new rules of thumb for rehab hours and dollars per patient day (PPD) like we have for nursing today. Nursing minutes are not part of the reimbursement formula today, like rehab minutes are not part of the formula under RCS1. Today, we see some Medicaid-dominant facilities staffing nursing at 2.8 hours ppd. High-acuity, short-term facilities may staff around 4.5 hours ppd. What’s the regulator for staffing the cost-center known as Nursing? Patient need/outcomes. I believe we’ll see rehab staffing in facilities in a similar way.

What about investors & valuation?

My focus so far has been at the operator/facility level. But how will underwriting and valuations of facilities change in 2018 and 2019? I think it’s safe to say, our current underwriting models will need major updating if RCS-1 goes through as proposed.

This article was originally published on McKnight’s here: http://www.mcknights.com/guest-columns/rcs-1-says-goodbye-to-rehab-yes-no/article/695499/ 

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Monkeys: LIBERATING Time Management Concept [Video]

Monkeys are the “leading cause of death” of new leaders.

Recent conversations with a few new(er) leaders about this common pitfall, prompted me to post this here. If you don’t have time (28 min) to watch this, then you probably really need to watch this. 😉

This time management concept saved my professional life.

After about 7 years in operations of skilled nursing facilities at The Ensign Group, a skilled nursing, seniors housing, home health & hospice, and radiology company, I spent 5 years there as the Chief Human Capital Officer. What an exciting time. Ensign’s “First Who, Then What” approach to growth meant we had to attract and train a lot of AITs into facility-level CEOs fast.  Over those 5 years, I personally participated in the training of about 100 new leaders. Week long boot camps, case studies, online tests, conference calls, assignments, analysis, etc.  I saw, up close and personal, what helped new leaders succeed … and fail.  

Monkeys has a lot to do with both.

I’ve trained the topic to groups in the hundreds at association conferences to 1:1. And, I wrote about monkeys years ago here:

But, this is the video that gives a thorough explanation of Monkeys and that my colleagues and friends have found most useful to understand the time management concept from theory to practical application.  While there are several healthcare operations and Ensign references, the principles are universal.

I hope it helps you or someone you know:

 

Wind of Change

Over 440,000,000 views on Youtube?!  The Scorpions’ Wind of Change music video (below) has been viewed a lot. It’s probably not the best anthem for the post-acute world, but the title sure seems to fit.  If there’s anything that’s constant for skilled nursing providers, it’s that things are always changing.


BPCI/CJR Loses Steam

Last year, I wrote about how the best operators are able to adjust or “change tack” to shifting winds/regulations. (mixing boating metaphors)

I also wrote specifically about one such shift that was causing a lot of concern for providers (and investors), Bundled Payments.

In recent days, we’ve seen the wind change direction again.  And, while nobody should be surprised, I think most of us are surprised.

  1. CMS is Overhauling the Medicare Fraud Audit Process
  2. CMS is canceling the expansion of CJR
  3. CMS is eliminating the Mandatory nature of CJR
  4. CMS is reducing the number of CJR markets from 67 to 34

It’s critical that operators who are currently being affected by the CJR program to get in touch with their hospitals to discuss what, if any, impact this will have on how the hospital is operating or is preparing to operate vis-a-vis these patients.

Skilled Nursing groups are applauding the news.  IF this gives providers more time to get their BPCI act together, then that’s great.  But, the point is … they still need to act like BPCI is coming.  BPCI behavior that better health plans and hospitals are looking for is:

  • Proactive communication around readmission and outcomes
  • Integration of hospital’s modalities into the SNF
  • Strong reporting systems
  • Proactive cost containment (shortening length of stay if possible)
  • Partnering with the best home health agencies who understand BPCI as well

Investors are looking for operators who are not just fluent in BPCI but has already (or is actively) implemented those BPCI Behaviors.


RUG IV to RCS1

In my opinion, a much bigger wind of change, if implemented on October 1, 2018 as targeted, is the shift from RUG IV to RCS1.  I attended a conference on that last week by Zimmet Healthcare Services Group in Atlantic City, NJ.

According to Mark Zimmet (https://www.zhealthcare.com/), the announced pre-rule for RCS by CMS (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html) earlier this year will dramatically change the way SNFs are operated — specifically replacing the REHAB/Minutes economic engine of operations with a Patient Characteristics economic engine.  Now, Medicare A reimbursement is driven mostly my rehab minutes (type and quantity).  In the proposed RCS 1 model, rehab minutes are completely excluded from the calculation. There is a PT/OT and an ST component in the formula.  But, minutes are NOT part of it.  In other words, under RCS 1, the facility will be paid the same amount for Patient John Doe whether the SNF provides 10 minutes of therapy or 1,000 minutes.  Panelists predict therapy spend will shrink AT LEAST 50%.

The driver of reimbursement shifts away from rehab minutes to patient clinical characteristics. RCS starts with WHY is the patient here.  Which of the 10 categories?

  1. Major Joint or Spinal
  2. Non-Orthopeadic
  3. Acute Neurologic
  4. Non-surgical orthopedic/Musculoskeletal
  5. Orthopedic Surgery (Except Major Joint)
  6. Cancer
  7. Acute Infections
  8. Pulmonary
  9. Cardiovascular & Coagulations
  10. Medical Management

Then, it looks at the functional and cognitive scores, co-morbidities, non-therapy ancillaries.

Remember …

  1. The change isn’t final and may very well change before it’s implemented.
  2. There’s time to recalibrate your structure and competency to hit the ground running if/when the change is made.
  3. I would be talking now with your rehab provider about this.  The message from this conference is that Rehab Co’s in skilled nursing are Dead Man Walking.
  4. Stay up to date on the CMS conference calls, updates.

Goodbye Therapy?

If RCS 1 is implemented as structured today, I would expect the use of therapy services to change and be reduced.  In a word, I believe therapy will be more EFFICIENT. Unfortunately, CMS now incentivizes inefficiency since providers are paid for the minutes they take to deliver therapy.  Does this get abused?  Sadly, yes.  Do we sometimes see a patient who needs rest to recover from illness get dragged into the rehab gym to get our minutes in?  Sadly, yes. I’m totally open to viewpoints on this …  Is this better for the patient or worse?  Can you see operators cutting the newly labeled “cost center” of rehab and giving less than what the patient could benefit by since Medicare isn’t paying for minutes anymore?  I can.  But, I can also see operators providing a lot of therapy (but still less than before) under RCS 1 since they’re ultimately judged based on outcomes.  Almost all admissions to SNFs now are for short-term rehab to get strong enough to go home.  If you cut rehab to save money, you might benefit in the very short-run, but after a couple months, your readmission rate and patient satisfaction and length of stay will suffer.  I can’t imagine a world without Rehab being an essential part skilled nursing, RCS 1 or not.

So, look at Nursing under the RUGs system.  Nursing minutes/hours are not currently reimbursed — like rehab won’t be in the future.  The way operators staff their nursing departments, I believe, will be a predictor of how they staff their rehab departments under RCS 1.  Some Medicaid shops run as lean as possible b/c there simply isn’t enough revenue to support more.  Yet, short-term rehab shops, staff way higher than state minimums because quality care/outcomes/readmission rates/etc. demand it. I believe that will be the case for Rehab.

CMS is infamous for unintended consequences.  They consistently underestimate operators ability to quickly adapt to the moving goal posts.  So, while CMS predicts this will be budget neutral, I wouldn’t be surprised if it resulted in an increase in Medicare spend (and bottom line performance for SNFs), resulting in quick adjustments like we saw in 2011 and 2012.


Here are 3 videos I took of the presenter going through the calculator that shows the new formula at work (note: no input in the new calculator for minutes):

IMG_4619.jpg
This ballroom was packed for both days of presentations. Highly recommend Zimmet for learning about the latest changes to reimbursement & regulation in LTC

“Oversupply”

At the last NIC in Dallas, I caught up with an owner/operator of mid-market seniors housing. He has successfully made the transition from owning and operating hotels to assisted living and memory care.  We talked a bit about his hotel business and I found an interesting corollary to how I look at investing in the assisted living space.

There have been a lot of concerns about oversupply in seniors housing.  Newly developed and opened properties take market share from competition and both REITs (particularly those in RIDEA deals) and operators struggle, at least in the short-run, until occupancy stabilizes again.  I get asked this question a lot, “how are you looking at the over-supply concern?”  I like the question because it provides a forum for talking about the mid-market, B to B+ quality properties that is generally ignored by other REITs.  The beauty of investing in the mid-market seniors housing segment is

  1. you avoid the new construction pressures as the vast majority of new supply is A to A+ quality with all the bells and whistles, and
  2. if you invest primarily in secondary markets you further protect yourself from new construction risk.

In addition, the demand for quality seniors housing at the $3,500/month vs. $6,500/month (depending on the market) price point is huge and growing.  There’s a recent housing study by Harvard that highlights the growing supply/demand disparity for lower-income seniors housing.  So, to invest in a Ritz Carlton or Holiday Inn?  There’s certainly a market for both.  My recovering hotel investor friend in Dallas shared his experience, “I’d convert the hotel into a Holiday Inn; put out some coffee, juice, and bagels in the morning and you’re good.”  Luckily for investors and residents who choose to live there, there are quality operators who have figured out the recipe for providing a great place to live and work at an affordable price.

 

McKnight’s Guest Column: Bundled Payments

McKnight’s is a leading skilled nursing industry news source that I’ve written for in the past.  This is my first guest column since moving to the REIT side of the business.  We meet with investors and analysts a lot and one of their most pressing questions lately is around bundled payments/comprehensive care for joint replacements (CJR) so I wrote about my take on it for McKnight’s.  Click on the article below to read the full text.

Dave Sedgwick McKnight's CJR Skilled Nursing article

 

Or read it below …

“What’s your take on bundled payments?”

About a year ago, investors and analysts would occasionally ask us some form of that question. Now, virtually every time we talk with investors, analysts, and bankers, they ask. At the end of answering questions on the topic for 45 minutes during one of these recent meetings, the investor laughed and incredulously said, “So, basically you’re the only ones saying, ‘No big deal. Nothing to see here. Business as usual.” Well, yes. And, no.

There’s a lot of hand-wringing in the post-acute world these days as observers try to predict just how material the constant changes to reimbursement will be for the operators. It seems generally believed that bundled payments expansion is a net-negative for the industry since it partly exists to lower Medicare payments. There will be “losers” who don’t adapt to the changes. But, there will also be “winners.” There always have been. As a former operator and current investor in the space, I have a positive view on what these changes mean for the profession.

Context Is Key

Viva-La-Evolution

I entered the skilled nursing profession as an administrator-in-training at The Ensign Group in California in 2001. Back then, one of the first themes I picked up on from the seasoned ED/DNS/DORs around me was that, “this isn’t your grandmother’s nursing home anymore.” “No, you see, while we still provide long-term custodial (I will always hate that term) care, we now specialize in providing short-term rehabilitation for Medicare and HMO patients.”

For the last 15 years, the best operators have been adapting to the demands of the hospitals (higher acuity, readmission rates), CMS (MDS/RUGS changes, 5 star ratings, compliance), and HMOs (shorter length of stay, case management, collaboration).

“So are you worried about this Joint Replacement thing?

On April 1, 2016, the Comprehensive Care for Joint Replacement (CJR) went into effect in 67 markets. Briefly, the CJR holds the participating hospitals financially responsible for the episode of care from the day of admission until 90 days later for major joint replacement or reattachment of lower extremity joint replacements (LEJR), hips and knees. If a hospital can lower the cost of that 90 day episode of care below targets set by CMS, they will reap the financial rewards with a bonus. The opposite is also true. Some warn that allowing hospitals to waive the required three night hospitalization before discharging CJR patients to SNFs rated 3 star or better will crush the 1-2 rated facilities. Others warn that hospitals will be incentivized to send CJR patients directly home with Home Health, bypassing SNFs altogether, because of the cost savings. In my opinion, these predictions have been overblown. The sky is not falling.

Now sing it with me … “You Tell Me That’s It’s Evolution”

evolution-darth-vader

I understand why outside observers worry that this as a seismic shift for skilled nursing (and HH for that matter). How, then is CJR not the end of the world for post-acute facility providers? Again, I see CJR as a positive step for post-acute care because it advances trends that level the playing field for stronger operators, ultimately benefiting the patients. Here’s what I mean.

  • Length of stay: HMOs have been pressuring SNFs to shorten length of stay for many years. The last facility I personally ran was 100% short-term rehab. Our combined Medicare/HMO average length of stay was in the mid-teens. Strong providers have been equipping themselves to shorten length of stay for years. They will employ similar practices on these LEJR Medicare patients that they have been using on HMO patients, thus gaining CJR market share from those who don’t.
  • Case Management/Data Reporting: Try competing in a market where your competitors employ the hospital Discharge Planners as part-time Social Workers on the weekend or pay kickbacks for referrals. What? It happens. Today. I’ve competed against it. The only way we could “level the playing field” was to be BETTER. We had to build strong, data-driven (readmission rates, satisfaction scores, survey results, clinical outcomes) relationships with the hospitals that earned our admissions. We had to reach out to hospitals years before ACOs or BPCI to “show them the data!” How does CJR impact this? It should put a vice on the unethically influenced placement of patients and make the market for post-acute patients more merit based. For the many hospitals that didn’t care about their post-acute discharge system, now they will. Stronger operators are poised to gain CJR market share because of it.
  • CMS Star Rating: As soon as the star ratings came out years ago, we complained because the system doesn’t necessarily reflect quality care. In the short-run, hospital may use star ratings in their discharge calculus. But, they’ll evolve as well. SNFs who are 1 or 2 stars can still receive joint-replacmenet patients. And, here’s the thing, patients who are ready to be DC’d from the hospital after a night or two have already been heading home with HH for years. Patients that have to go to the SNF have an initial hospital stay past 3 days anyway.
  • Readmission Rates: At the end of the day, the cost of caring for that patient for 90 days depends greatly on whether or not the patient is readmitted to the hospital. Hospitals are going to be very sensitive to which post-acute location gives them better odds of not having a re-hospitilization. Where would you send them? To the strong SNF provider with 24-hour RN coverage, a medical director, in-house therapists, wound care professionals, etc. or the patient’s home with her elderly husband to care for her in between the hour or so/day she gets from HH. Both graphics below from Avalere, show hospitals the need to partner with SNFs with the lowest readmission rates. It’s no wonder CMS is adding readmission rates to the star rating system this summer.

Screen Shot 2016-03-27 at 3.09.39 PM Screen Shot 2016-03-31 at 3.49.54 PMWhile there may be a slight tightening on the flow of LEJR patients for the general industry (only for 67 markets for now), the strong providers will be able to capture greater share of that theoretical smaller piece. But, let’s not forget the rest of the pie! Sometimes it seems that outside observers focus so much on the joint-replacement piece of the patient pie that they forget a few key points:

  • SNFs are taking care of sicker and sicker patients every year (the kind that absolutely require 24-hour nursing care)
  • Seniors demographics haven’t changed. The numbers of SNF-age patients is growing and will continue to grow for many years to come. While a piece of the pie might shrink, the overall pie will be expanding for years to come.
  • As a general rule, the highest Medicare reimbursement occurs at the start of the SNF stay, sometimes “stepping down” towards the end. So, as providers shorten length of stay, they may see a slight increase to their average medicare reimbursement rate.

So, What?

So, what does this all mean for investing in skilled nursing real estate? It has always been true that in healthcare real estate, the operator matters most. The playing field has been changing for the last 15 years. BPCI/CJR actually has the potential of slightly leveling the playing field in behalf of stronger operators. BPCI/CJR can’t be ignored and should be a factor in underwriting acquisitions. Higher lease coverages and cap rates are in order for facilities with lower star ratings and higher readmission rates as those metrics become more and more impactful on a provider’s ability to shift patient mix and capture short-term rehab market share.

Today (and tomorrow), more than ever before, your SNF real estate investment will hinge on the quality, sophistication, and culture of the operator running it.

On Skilled Nursing Headwinds & Tailwinds

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If you invest in skilled nursing operators or real estate, you’ve seen the almost automatic drop in stock prices with every new “headwind” headline.  And, they come frequently.  Most recently: RAC Audits, CJR, Bundled Payments, DOJ Investigations.  I gotta admit, it’s frustrating to see the stocks move as soon as the weathervane moves.  Frustrating, because the best post-acute companies are able to adapt and thrive, or to put int terms of headwinds, they change tack…”

A keel enables a sailboat to sail diagonally into the wind. As the sail moves into the wind, it “feels” a faster wind on its face. This is called the relative velocity of the wind with respect to the sail. A wind of larger relative velocity exerts a larger force on the sail, which accelerates the boat. The boat moves faster, which increases the relative speed of the wind, which increases the wind-force, which accelerates the boat, and on and on. However, the resistance of the water slows down the motion of the boat. Eventually, a balance is reached between the force of the wind and the force of the water, and the boat moves at a constant velocity, diagonally into the wind. That final constant velocity may be greater than the wind velocity with respect to the water. Whether a boat could reach such final velocity will depend on the characteristics of the boat. [source]

Can a sailboat sail forward against the wind?  Yes.  You need a great captain and crew who know how to adapt, “change tack,” and move forward.  In a boat race, is there a huge difference in the boats themselves?  Not so much.  It’s the captain and crew you’re betting on.  Not just the collection of their individual talents but their chemistry.  Headwinds in skilled nursing provide more opportunity for the best SNF crews to differentiate themselves from the also-rans .

Because of the risks (headlines, stroke of the pen, state budgets), investing in skilled nursing facilities commands a higher, risk-adjusted return than almost any other real estate investment.  It’s not for the faint of heart.  The security of the rents produced by skilled nursing is more a function of the culture, engagement, and sophistication of the operator than of the latest wind of change.

Does the size of the boat matter? Not as much as you might think. When there was a  seismic shift to the industry in 1999 with the move from a cost plus basis to a prospective payment system (PPS)  several of the very large, “more sophisticated” operators failed to move quickly. It appears that their size,  bureaucracy may have prevented them from changing tack quickly enough. On the other hand, often times smaller operators  lack the resources and sophistications to change tack as well. So, it is less about the size of the company and more about the management teams and the culture/structure of their companies that will predict their ability to move forward.

There are two headlines I saw today that would suggest some tailwinds are in store for a change.

Possible delay two of joint replacement bundle

Pilot program to pay skilled nursing more (site neutral)

No doubt stock prices will tack up, right?  Riiiiiiiiiiiiiight.

Jim Rome, John Wooden, Skilled Nursing “Success”

When I was in High School, my buddies and I listened to a new, up-and-coming, cocky sports talk radio guy, Jim Rome.  He constantly played his verbal trump card against people critiquing successful players/teams.  He would simply respond by saying, “Scoreboard!

Does anyone have a better scoreboard than John Wooden?  The best coach in sport.  Scoreboard? 10 national championships at UCLA.  But, why do I love and respect and listen to the man?  Because of how he won.  Coach Wooden came to mind today because of a conversation with another guy who’s the “best” at his sport, my friend David Howell, a facility CEO for The Ensign Group in southern California. In my opinion, Howell’s one of the best SNF EDs in the country.   It’s almost unbelievable to see what he’s built out of his small SNF in a very blue-collar neighborhood.  His facility won Ensign’s highest total quality award today and he shared with me what he was planning on saying at the ceremony … Wooden, “C.S. Wooden” 😉

alg_wooden_net1

I want to share these two thoughts from a talk Coach Wooden gave and that Howell shared today as well.  But, you really ought to watch the whole talk below.

  1. Winning is not in the definition of success.  Here’s what C.S. Wooden said success is: Peace of mind attained only through self-satisfaction in knowing you made the effort to do the best of which you’re capable. I believe that’s true. If you make the effort to do the best of which you’re capable, trying to improve the situation that exists for you, I think that’s success, and I don’t think others can judge that; it’s like character and reputation — your reputation is what you’re perceived to be; your character is what you really are. And I think that character is much more important than what you are perceived to be. You’d hope they’d both be good, but they won’t necessarily be the same. Well, that was my idea that I was going to try to get across to the youngsters.”

  2. This.  Poem by George Moriarty, called The Road Ahead, Or The Road Behind.”
    “Sometimes I think the Fates must grin as we denounce them and insist the only reason we can’t win, is the Fates themselves have missed.

    Yet there lives on the ancient claim: we win or lose within ourselves. The shining trophies on our shelves can never win tomorrow’s game.

    You and I know deeper down, there’s always a chance to win the crown. But when we fail to give our best, we simply haven’t met the test, of giving all and saving none until the game is really won;

    of showing what is meant by grit; of playing through when others quit; of playing through, not letting up. It’s bearing down that wins the cup.

    Of dreaming there’s a goal ahead; of hoping when our dreams are dead; of praying when our hopes have fled; yet losing, not afraid to fall, if, bravely, we have given all.

    For who can ask more of a man than giving all within his span. Giving all, it seems to me, is not so far from victory. And so the Fates are seldom wrong, no matter how they twist and wind.

    It’s you and I who make our fates — we open up or close the gates on the road ahead or the road behind.”

Congratulations to David, Lito, and the entire Brookfield team.  You’ve been a stunning SUCCESS for many years before winning the Flag today.